Health Options Program

Transcription

1 Pennsylvania Public School Employees Retirement System (PSERS) Health Options Program Comprehensive Prescription Drug Formulary (List of Covered Drugs) 2016 FOR THE ENHANCED, BASIC AND VALUE MEDICARE Rx OPTIONS PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THESE PLANS. This formulary was updated on January 1, For more recent information or other questions, please contact OptumRx at , 24 hours a day, 7 days a week. TTY users should call You can also visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means the Health Options Program, which is sponsored by the Pennsylvania Public School Employees Retirement System. When it refers to plan or our plan, it means the Enhanced, Basic or Value Medicare Rx Option. This document includes a list of the drugs (formulary) for our plans which is current as of January 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 2017, and from time to time during the year. What is the Formulary? A formulary is a list of drugs selected by the Enhanced, Basic and Value Medicare Rx Options in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The Enhanced, Basic and Value Medicare Rx Options will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, and other Plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Please note that this formulary covers the Enhanced, Basic and Value Medicare Rx Options only. If you have coverage through a Medicare Advantage plan through the Health Options Program, you will have to contact the Medicare Advantage plan directly for a copy of the formulary for your prescription drug plan. CMS CONTRACT NUMBER: E3014

2 Can the formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, To get updated information about the drugs covered by the Enhanced, Basic and Value Medicare Rx Options, please contact us. Our contact information appears on the front and back cover pages. In the event of midyear formulary changes, a revised Comprehensive Formulary will be posted to How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 83. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? The Enhanced, Basic and Value Medicare Rx Options cover both brand-name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs have special requirements or limits on coverage. These requirements and limits may include: First Fill Starter Quantity: Maintenance medication is any medication that your doctor feels you should take on a regular basis for an extended period of time for a chronic or long-term medical condition. The ii

3 Enhanced, Basic and Value Medicare Rx Options will cover up to a 90-day supply of a maintenance medication, but you must first obtain up to a 30-day supply, or a first fill starter quantity. Starting with a smaller quantity allows you to make sure the drug provides the intended benefits without unintended side effects. If you are taking a maintenance medication, it needs to be taken regularly in order for it to be effective in treating your condition. Therefore, if you have a lapse of more than 180 days (six months) before requesting a refill of a maintenance medication, you will be required to meet the first fill starter quantity again to make sure you can take the medication safely and effectively. Prior Authorization (PA): The Enhanced, Basic and Value Medicare Rx Options require you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from the Enhanced, Basic or Value Medicare Rx Option before you fill your prescriptions. If you don t get approval, the Enhanced, Basic or Value Medicare Rx Option may not cover the drug. Quantity Limits (QL): For certain drugs, the Enhanced, Basic and Value Medicare Rx Options limit the amount of the drug that will be covered. For example, the Enhanced, Basic and Value Medicare Rx Options cover 30 pills per 30 days for Crestor. If your prescription is for more, OptumRx will contact your doctor to determine whether more than one per day will be covered. Step Therapy (ST): In some cases, the Enhanced, Basic and Value Medicare Rx Options require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the Enhanced, Basic and Value Medicare Rx Options may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask the Enhanced, Basic or Value Medicare Option to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Enhanced, Basic and Value Medicare Rx Options formulary? on page iv for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact OptumRx and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that the Enhanced, Basic and Value Medicare Rx Options do not cover your drug, you have two options: You can ask OptumRx for a list of similar drugs that are covered by the Enhanced, Basic and Value Medicare Rx Options. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan. You can ask your plan to make an exception and cover your drug. See below for information about how to request an exception. iii

4 How do I request an exception to the Enhanced, Basic and Value Medicare Rx Options formulary? You can ask your plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level (if this drug is not on the specialty tier). If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the Enhanced, Basic and Value Medicare Rx Options limit the amount of drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, the Enhanced, Basic or Value Medicare Rx Option will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or prescribing physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. iv

5 For those members who were in the plan last year, we will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a 31-day supply or less if your prescription is written for fewer days. This transition policy applies only to those drugs that are covered under the Basic or Value Medicare Rx Option and filled at a network pharmacy. For More Information For more detailed information about the Enhanced, Basic and Value Medicare Rx Options, please review your Evidence of Coverage and other plan materials. If you have questions about the Enhanced, Basic and Value Medicare Rx Options, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or visit Medicare-Excluded Drugs Covered under the Enhanced Medicare Rx Option Only Certain Medicare-excluded drugs are covered under the Enhanced Medicare Rx Option, but not the Basic Medicare Rx Option. A list of these drugs can be found beginning on page 113. How to Read the Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by the Enhanced, Basic and Value Medicare Rx Options. If you have trouble finding your drug in the list, turn to the Index that begins on page 83. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., meloxicam). The information in the Requirements/Limits column tells you if the Enhanced, Basic and Value Medicare Options have any special requirements for coverage of your drug. WHAT THE ABBREVIATIONS MEAN B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PA: Prior Authorization. You or your physician need to get approval from the Enhanced, Basic or Value Medicare Rx Option before you fill this prescription. If you don t get approval, the Enhanced, Basic or Value Medicare Rx Option may not cover the drug. See page iii for more information. QL: Quantity Limit. The Enhanced, Basic and Value Medicare Rx Options limit the amount of this drug that will be covered. See page iii for more information. ST: Step Therapy. The Enhanced, Basic and Value Medicare Rx Options require you to first try another drug to treat your medical condition before we will cover this one for that condition. See page iii for more information. v

6 2016 Comprehensive Prescription Drug Formulary DEDUCTIBLE You must pay Medicare s annual deductible of $360 before the Value Medicare Rx Option pays any portion of your prescription drug costs. The Enhanced and Basic Medicare Rx Options pay Medicare s annual deductible for you. GENERIC S (TIER 1) In Initial Coverage, if you are enrolled in the Enhanced Medicare Rx Option, you ll pay $7 for up to a 30-day supply (and $21 for a 31- to 90-day supply). In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you ll pay $8 for up to a 30-day supply (and $24 for a 31- to 90-day supply). In Initial Coverage, if you are enrolled in the Value Medicare Rx Option, you ll pay 25% of the cost after you satisfy Medicare s annual deductible. In the Coverage Gap, if you are enrolled in the Enhanced Medicare Rx Option, you ll pay $7 for up to a 30-day supply and $21 for a 31- to 90-day supply. In the Coverage Gap, if you are enrolled in the Basic Medicare Rx Option, you ll pay 58% of the cost. In the Coverage Gap, if you are enrolled in the Value Medicare Rx Option, you ll pay 58% of the cost. PREFERRED BRAND-NAME S (TIER 2) In Initial Coverage, if you are enrolled in the Enhanced Medicare Rx Option, you ll pay 25% to a maximum of $65 for up to a 30-day supply and $130 ($120 if you use mail order) for a 31- to 90-day supply. In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you ll pay 30% of the cost to a maximum of $100 for up to a 30-day supply and $250 ($225 if you use mail order) for a 31- to 90-day supply. In Initial Coverage, if you are enrolled in the Value Medicare Rx Option, you ll pay 25% of the cost after you satisfy Medicare s annual deductible. In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, you ll pay 45% of the cost. NON-PREFERRED BRAND-NAME S (TIER 3) In Initial Coverage, if you are enrolled in the Enhanced Medicare Rx Option, you ll pay 35% of the cost to a maximum of $75 for up to a 30- day supply and $150 ($140 if you use mail order) for a 31- to 90-day supply. In Initial Coverage, if you are enrolled in the Basic Medicare Rx Option, you ll pay 40% of the cost. In Initial Coverage, if you are enrolled in the Value Medicare Rx Option, you ll pay 25% of the cost after you satisfy Medicare s annual deductible. In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, you ll pay 45% of the cost. SPECIALTY S (TIER 4) In Initial Coverage, if you are enrolled in the Enhanced or Basic Medicare Rx Option, you pay 33% of the cost. In Initial Coverage, if you are enrolled in the Value Medicare Rx Option, you ll pay 25% of the cost after you satisfy Medicare s annual deductible. In the Coverage Gap, if you are enrolled in the Enhanced, Basic or Value Medicare Rx Option, your cost for a Specialty generic drug is the same as your cost for any other generic drug, and your cost for a Specialty brand-name drug is the same as your cost for any other brandname drug. vi

7 Analgesics Analgesics BUPAP TABS 300MG; 50MG 2 QL (180 EA per 30 days) PA butalbital/acetaminophen 1 QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine caps 1 QL (180 EA per 30 days) PA butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 1 QL (180 EA per 30 days) PA butalbital/apap/caffeine 1 QL (180 EA per 30 days) PA butalbital/aspirin/caffeine caps 1 QL (180 EA per 30 days) PA ESGIC TABS 3 QL (180 EA per 30 days) PA FIORICET CAPS 3 QL (180 EA per 30 days) PA FIORINAL 3 QL (180 EA per 30 days) PA vanatol lq 1 QL (2700 ML per 30 days) PA Nonsteroidal Anti-inflammatory Drugs ANAPROX 3 ST ANAPROX DS 3 ST ARTHROTEC 50 3 ST ARTHROTEC 75 3 ST CAMBIA 2 CELEBREX CAPS 200MG, 400MG, 50MG 3 QL (60 EA per 30 days) CELEBREX CAPS 100MG 3 QL (90 EA per 30 days) celecoxib caps 200mg, 400mg, 50mg 1 QL (60 EA per 30 days) celecoxib caps 100mg 1 QL (90 EA per 30 days) DAYPRO 3 ST diclofenac potassium 1 diclofenac sodium dr 1 diclofenac sodium er 1 diclofenac sodium/misoprostol 1 diclofenac sodium transdermal soln 1.5% 1 diflunisal tabs 1 DUEXIS 4 QL (90 EA per 30 days) ST EC-NAPROSYN 3 ST etodolac er 1 etodolac caps, tabs 1 FELDENE 3 ST fenoprofen calcium tabs 1 FLECTOR 2 PA flurbiprofen tabs 1 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg 1 INDOCIN SUSP 2 PA indomethacin er 1 PA indomethacin caps 1 PA ketoprofen er 1 ketoprofen caps 1 ketorolac tromethamine inj 30mg/ml 1 QL (20 ML per 30 days) PA ketorolac tromethamine inj 15mg/ml 1 QL (40 ML per 30 days) PA 1

8 ketorolac tromethamine tabs 10mg 1 QL (20 EA per 5 days) PA meclofenamate sodium caps 1 mefenamic acid caps 1 meloxicam susp 1 meloxicam tabs 15mg 1 QL (30 EA per 30 days) meloxicam tabs 7.5mg 1 QL (60 EA per 30 days) MOBIC SUSP 3 ST MOBIC TABS 15MG 3 QL (30 EA per 30 days) ST MOBIC TABS 7.5MG 3 QL (60 EA per 30 days) ST nabumetone 1 NAPRELAN TB24 375MG, 500MG, 750MG 4 ST NAPROSYN TABS 3 ST naproxen dr 1 naproxen sodium er 1 naproxen sodium tabs 275mg, 550mg 1 naproxen susp, tabs 1 oxaprozin 1 PENNSAID 2 piroxicam caps 1 PONSTEL 4 ST SPRIX 2 QL (5 EA per 5 days) sulindac tabs 1 TIVORBEX 2 QL (90 EA per 30 days) PA tolmetin sodium caps 1 tolmetin sodium tabs 600mg 1 VIMOVO 4 QL (60 EA per 30 days) VOLTAREN 3 VOLTAREN-XR 3 ZIPSOR 2 ST ZORVOLEX 2 ST Opioid Analgesics, Long-acting BUPRENEX 4 buprenorphine hcl inj 0.3mg/ml 1 BUTRANS 2 QL (4 EA per 28 days) PA DOLOPHINE 3 QL (360 EA per 30 days) DOLOPHINE HCL 3 QL (360 EA per 30 days) DURAGESIC PT72 12MCG/HR, 25MCG/HR 3 QL (15 EA per 30 days) DURAGESIC PT72 50MCG/HR 4 QL (15 EA per 30 days) DURAGESIC PT72 100MCG/HR, 75MCG/HR 4 QL (30 EA per 30 days) EMBEDA CPCR 20MG; 0.8MG 2 QL (120 EA per 30 days) EMBEDA CPCR 30MG; 1.2MG, 50MG; 2MG 2 QL (60 EA per 30 days) EMBEDA CPCR 80MG; 3.2MG 4 QL (120 EA per 30 days) EMBEDA CPCR 60MG; 2.4MG 4 QL (180 EA per 30 days) EMBEDA CPCR 100MG; 4MG 4 QL (90 EA per 30 days) EXALGO T24A 12MG, 8MG 3 QL (180 EA per 30 days) EXALGO T24A 16MG, 32MG 4 QL (180 EA per 30 days) 2

9 fentanyl pt72 12mcg/hr, 25mcg/hr, 37.5mcg/hr, 50mcg/hr 1 QL (15 EA per 30 days) fentanyl pt72 100mcg/hr, 75mcg/hr 1 QL (30 EA per 30 days) fentanyl pt mcg/hr, 87.5mcg/hr 4 QL (15 EA per 30 days) hydromorphone hcl er t24a 8mg 1 QL (180 EA per 30 days) hydromorphone hcl er t24a 12mg, 16mg, 32mg 4 QL (180 EA per 30 days) HYSINGLA ER 3 QL (30 EA per 30 days) PA KADIAN CP24 10MG, 20MG, 30MG, 40MG 3 QL (120 EA per 30 days) ST KADIAN CP24 50MG, 60MG, 80MG 4 QL (120 EA per 30 days) ST KADIAN CP24 100MG, 200MG 4 QL (180 EA per 30 days) ST levorphanol tartrate tabs 1 QL (480 EA per 30 days) methadone hcl oral soln 1 QL (1800 ML per 30 days) methadone hcl tabs 1 QL (360 EA per 30 days) methadone hcl inj 4 morphine sulfate er cp24 10mg, 20mg, 30mg, 45mg, 50mg, 1 QL (120 EA per 30 days) 60mg, 75mg, 80mg, 90mg morphine sulfate er cp24 120mg 1 QL (180 EA per 30 days) morphine sulfate er cp24 100mg 4 QL (180 EA per 30 days) morphine sulfate er tbcr 15mg, 30mg, 60mg 1 QL (120 EA per 30 days) morphine sulfate er tbcr 100mg, 200mg 1 QL (180 EA per 30 days) MS CONTIN TBCR 15MG, 30MG 3 QL (120 EA per 30 days) MS CONTIN TBCR 60MG 4 QL (120 EA per 30 days) MS CONTIN TBCR 100MG, 200MG 4 QL (180 EA per 30 days) NUCYNTA ER 2 QL (60 EA per 30 days) OPANA ER (CRUSH RESISTANT) T12A 10MG, 15MG, 2 QL (120 EA per 30 days) 20MG, 5MG, 7.5MG OPANA ER (CRUSH RESISTANT) T12A 30MG, 40MG 4 QL (120 EA per 30 days) OXYCODONE HCL ER T12A 10MG, 20MG, 40MG 2 QL (120 EA per 30 days) ST OXYCODONE HCL ER T12A 80MG 2 QL (180 EA per 30 days) ST OXYCONTIN T12A 10MG, 15MG, 20MG, 30MG, 40MG, 2 QL (120 EA per 30 days) ST 60MG OXYCONTIN T12A 80MG 2 QL (180 EA per 30 days) ST oxymorphone hydrochloride er 1 QL (120 EA per 30 days) tramadol hcl er tb24 1 QL (30 EA per 30 days) ULTRAM ER 3 QL (30 EA per 30 days) ST XARTEMIS XR 2 QL (360 EA per 30 days) ZOHYDRO ER C12A 3 QL (60 EA per 30 days) PA Opioid Analgesics, Short-acting ABSTRAL 4 QL (120 EA per 30 days) PA acetaminophen/codeine #3 1 QL (360 EA per 30 days) acetaminophen/codeine soln 1 QL (4500 ML per 30 days) acetaminophen/codeine tabs 300mg; 60mg 1 QL (180 EA per 30 days) acetaminophen/codeine tabs 300mg; 15mg 1 QL (390 EA per 30 days) ACTIQ 4 QL (120 EA per 30 days) PA ascomp/codeine 1 QL (180 EA per 30 days) butalbital/acetaminophen/caffeine/codeine 1 QL (180 EA per 30 days) butorphanol tartrate inj 1 3

10 butorphanol tartrate nasal soln 1 QL (5 ML per 1 days) CAPITAL/CODEINE 2 QL (4500 ML per 30 days) carisoprodol/aspirin/codeine 1 PA codeine sulfate tabs 1 QL (180 EA per 30 days) DEMEROL INJ 50MG/ML 3 PA DEMEROL TABS 100MG 3 QL (270 EA per 30 days) DEMEROL TABS 50MG 3 QL (540 EA per 30 days) PA DILAUDID-HP INJ 10MG/ML 3 DILAUDID TABS 3 QL (360 EA per 30 days) DILAUDID LIQD 3 QL (4800 ML per 30 days) DILAUDID INJ 2MG/ML, 4MG/ML 3 duramorph 1 endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1 QL (360 EA per 30 days) endodan 1 QL (360 EA per 30 days) fentanyl citrate oral transmucosal lpop 200mcg 1 QL (120 EA per 30 days) PA fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 4 QL (120 EA per 30 days) PA 400mcg, 600mcg, 800mcg FENTORA 4 QL (120 EA per 30 days) PA FIORICET/CODEINE 3 QL (180 EA per 30 days) FIORINAL/CODEINE #3 3 QL (180 EA per 30 days) HYCET 3 QL (5550 ML per 30 days) hydrocodone bitartrate/acetaminophen soln 1 QL (5550 ML per 30 days) hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg 1 QL (360 EA per 30 days) hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg 1 QL (390 EA per 30 days) hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 1 QL (360 EA per 30 days) 325mg; 7.5mg hydrocodone/ibuprofen tabs 7.5mg; 200mg 1 QL (150 EA per 30 days) hydromorphone hcl tabs 1 QL (360 EA per 30 days) hydromorphone hcl liqd 1 QL (4800 ML per 30 days) hydromorphone hcl inj 500mg/50ml 1 IBUDONE TABS 10MG; 200MG 3 QL (150 EA per 30 days) LAZANDA 3 QL (30 EA per 30 days) PA lorcet 1 QL (360 EA per 30 days) lorcet hd 1 QL (360 EA per 30 days) lorcet plus tabs 325mg; 7.5mg 1 QL (360 EA per 30 days) lortab tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1 QL (360 EA per 30 days) meperidine hcl oral soln 1 PA meperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml 1 PA meperitab tabs 100mg 1 QL (270 EA per 30 days) meperitab tabs 50mg 1 QL (540 EA per 30 days) PA morphine sulfate tabs 1 QL (360 EA per 30 days) morphine sulfate inj 10mg/ml, 2mg/ml, 4mg/ml, 8mg/ml 1 morphine sulfate oral soln 20mg/5ml 1 QL (2700 ML per 30 days) morphine sulfate oral soln 10mg/5ml 1 QL (3600 ML per 30 days) morphine sulfate oral soln 20mg/ml 1 QL (540 ML per 30 days) 4

11 nalbuphine hcl inj 1 NORCO 3 QL (360 EA per 30 days) NUCYNTA TABS 50MG, 75MG 3 QL (180 EA per 30 days) NUCYNTA TABS 100MG 3 QL (210 EA per 30 days) OPANA TABS 5MG 3 QL (180 EA per 30 days) OPANA TABS 10MG 4 QL (180 EA per 30 days) oxycodone hcl conc 1 QL (360 ML per 30 days) oxycodone hcl caps, tabs 1 QL (480 EA per 30 days) oxycodone hcl soln 1 QL (7200 ML per 30 days) oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 1 QL (360 EA per 30 days) 325mg; 5mg, 325mg; 7.5mg oxycodone/aspirin 1 QL (360 EA per 30 days) oxycodone/ibuprofen 1 QL (120 EA per 30 days) oxymorphone hydrochloride 1 QL (180 EA per 30 days) pentazocine/naloxone hcl 1 QL (360 EA per 30 days) PA PERCOCET TABS 325MG; 2.5MG 3 QL (360 EA per 30 days) PERCOCET TABS 325MG; 10MG, 325MG; 5MG, 325MG; 4 QL (360 EA per 30 days) 7.5MG PERCODAN 3 QL (360 EA per 30 days) PRIMLEV TABS 300MG; 5MG 2 QL (390 EA per 30 days) PRIMLEV TABS 300MG; 10MG, 300MG; 7.5MG 4 QL (390 EA per 30 days) REPREXAIN TABS 2.5MG; 200MG 2 QL (150 EA per 30 days) REPREXAIN TABS 10MG; 200MG, 5MG; 200MG 3 QL (150 EA per 30 days) ROXICET SOLN 2 QL (1860 ML per 30 days) ROXICODONE TABS 15MG, 5MG 3 QL (480 EA per 30 days) ROXICODONE TABS 30MG 4 QL (480 EA per 30 days) SUBSYS LIQD 100MCG, 200MCG, 400MCG, 600MCG, 4 QL (360 EA per 30 days) PA 800MCG SYNALGOS-DC 3 QL (360 EA per 30 days) TALWIN 2 PA tramadol hcl tabs 1 QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen 1 QL (240 EA per 30 days) trezix caps 320.5mg; 30mg; 16mg 1 QL (300 EA per 30 days) TYLENOL/CODEINE #3 3 QL (360 EA per 30 days) TYLENOL/CODEINE #4 3 QL (180 EA per 30 days) ULTRACET 3 QL (240 EA per 30 days) ULTRAM 3 QL (240 EA per 30 days) ST vicodin es tabs 300mg; 7.5mg 1 QL (390 EA per 30 days) vicodin hp tabs 300mg; 10mg 1 QL (390 EA per 30 days) vicodin tabs 300mg; 5mg 1 QL (390 EA per 30 days) VICOPROFEN 3 QL (150 EA per 30 days) XODOL TABS 300MG; 5MG 3 QL (390 EA per 30 days) XODOL TABS 300MG; 10MG, 300MG; 7.5MG 4 QL (390 EA per 30 days) zamicet 1 QL (5400 ML per 30 days) Anesthetics Local Anesthetics 5

12 EMLA 3 lidocaine hcl jelly 1 lidocaine hcl external soln 1 lidocaine hcl inj 0.5%, 2% 1 B/D lidocaine viscous 1 lidocaine/prilocaine crea 1 lidocaine oint 1 lidocaine ptch 1 QL (90 EA per 30 days) PA LIDODERM 3 QL (90 EA per 30 days) PA XYLOCAINE EXTERNAL SOLN 3 XYLOCAINE INJ 2% 3 B/D Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 1 ANTABUSE 3 disulfiram tabs 1 naltrexone hcl tabs 1 VIVITROL 4 PA Opioid Dependence Treatments BUNAVAIL 3 QL (60 EA per 30 days) PA buprenorphine hcl/naloxone hcl 1 QL (90 EA per 30 days) buprenorphine hcl subl 2mg, 8mg 1 QL (90 EA per 30 days) SUBOXONE FILM 12MG; 3MG, 4MG; 1MG 3 QL (60 EA per 30 days) SUBOXONE FILM 2MG; 0.5MG, 8MG; 2MG 3 QL (90 EA per 30 days) ZUBSOLV SUBL 8.6MG; 2.1MG 3 QL (60 EA per 30 days) ZUBSOLV SUBL 1.4MG; 0.36MG, 5.7MG; 1.4MG 3 QL (90 EA per 30 days) Opioid Reversal Agents EVZIO 2 naloxone hcl inj 1mg/ml 1 Smoking Cessation Agents buproban 1 QL (60 EA per 30 days) CHANTIX CONTINUING MONTH PAK 2 QL (60 EA per 30 days) PA CHANTIX STARTING MONTH PAK 2 QL (53 EA per 28 days) PA CHANTIX TABS 0.5MG, 1MG 2 QL (60 EA per 30 days) PA NICOTROL INHALER 2 QL (3024 EA per 180 days) NICOTROL NS 2 QL (720 ML per 180 days) ZYBAN 3 QL (60 EA per 30 days) Antibacterials Aminoglycosides amikacin sulfate inj 500mg/2ml 1 BETHKIS 4 B/D GARAMYCIN SOLN 3 gentak 1 GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE INJ 2 0.9MG/ML; 0.9%, 1.4MG/ML; 0.9% 6

13 gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%, 1 1mg/ml; 0.9% gentamicin sulfate crea, inj, external oint, ophthalmic oint, 1 ophthalmic soln isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9% 1 neomycin sulfate 1 paromomycin sulfate 1 STREPTOMYCIN SULFATE INJ 3 TOBI 4 B/D TOBRAMYCIN SULFATE/SODIUM CHLORIDE INJ 0.9%; 2 0.8MG/ML tobramycin sulfate ophthalmic soln 1 tobramycin sulfate inj 10mg/ml, 80mg/2ml 1 tobramycin nebu 4 B/D TOBREX OINT 2 TOBREX SOLN 3 Antibacterials, Other ALTABAX 2 baciim 1 bacitracin inj, oint 1 BACTRIM 3 BACTRIM DS 3 BACTROBAN 3 BACTROBAN NASAL 2 chloramphenicol sodium succinate 1 CLEOCIN IN D5W 3 CLEOCIN PEDIATRIC GRANULES 3 CLEOCIN PHOSPHATE INJ 900MG/6ML 3 CLEOCIN SUPP 2 CLEOCIN CAPS, CREA 3 clindamycin hcl caps 1 clindamycin palmitate hcl 1 clindamycin phosphate add-vantage 1 clindamycin phosphate in d5w 1 clindamycin phosphate crea 2% 1 colistimethate sodium 4 CUBICIN 4 DALVANCE 4 PA DORIBAX 2 FLAGYL 3 FLAGYL ER 2 FURADANTIN 4 HIPREX 3 LINCOCIN 2 linezolid 4 PA MACROBID 3 QL (90 EA per 365 days) 7

14 MACRODANTIN CAPS 25MG 2 QL (90 EA per 365 days) MACRODANTIN CAPS 100MG, 50MG 3 QL (90 EA per 365 days) methenamine hippurate 1 METROCREAM 3 METROGEL 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole in nacl 0.79% 1 metronidazole vaginal 1 metronidazole caps, crea, gel, lotn, tabs 1 MONUROL 2 mupirocin crea, oint 1 neomycin/polymyxin b sulfates 1 nitrofurantoin macrocrystals 1 QL (90 EA per 365 days) nitrofurantoin monohydrate 1 QL (90 EA per 365 days) nitrofurantoin susp 1 NORITATE 4 NUVESSA 2 polymyxin b sulfate inj 1 PRIMSOL 2 SIVEXTRO 4 PA sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 SULFAMYLON CREA 2 SULFAMYLON PACK 4 SYNERCID 4 trimethoprim tabs 1 TYGACIL 4 VANCOCIN HCL 4 PA vancomycin hcl caps 4 PA vancomycin hcl inj 1000mg, 10gm, 500mg 1 vandazole 1 XIFAXAN 4 ZYVOX 4 PA Beta-lactam, Cephalosporins CEDAX 3 cefaclor er 1 cefaclor caps 1 CEFACLOR SUSR 125MG/5ML, 375MG/5ML 2 cefaclor susr 250mg/5ml 1 cefadroxil 1 cefazolin sodium inj 10gm, 1gm; 5%, 1gm, 500mg 1 cefdinir 1 cefditoren pivoxil tabs 200mg 1 cefepime inj 1gm/50ml; 5%, 1gm, 2gm/50ml; 5%, 2gm 1 cefixime 1 8

15 cefotaxime sodium inj 1gm, 2gm, 500mg 1 CEFOTETAN 3 CEFOXITIN SODIUM INJ 1GM; 4%, 2GM; 2.2% 3 cefoxitin sodium inj 10gm, 1gm, 2gm 1 cefpodoxime proxetil 1 cefprozil 1 ceftazidime/dextrose 1 ceftazidime inj 1gm, 2gm, 6gm 1 CEFTIN SUSR 3 CEFTIN TABS 250MG 3 CEFTIN TABS 500MG 4 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg 1 cefuroxime axetil tabs 1 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1 cephalexin 1 CLAFORAN INJ 2GM 2 CLAFORAN INJ 10GM, 1GM, 2GM, 500MG 3 FORTAZ INJ 1GM, 2GM, 6GM 3 KEFLEX 3 MAXIPIME 3 SPECTRACEF TABS 400MG 3 SUPRAX CAPS, CHEW 2 SUPRAX SUSR 100MG/5ML, 500MG/5ML 2 SUPRAX SUSR 200MG/5ML 3 tazicef inj 1gm, 2gm, 6gm 1 TEFLARO 4 ZERBAXA 4 PA ZINACEF INJ 1.5GM, 7.5GM, 750MG 3 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE 2 AZACTAM INJ 1GM 3 aztreonam inj 1gm 1 imipenem/cilastatin 1 INVANZ 2 meropenem inj 500mg 1 MERREM INJ 500MG 3 PRIMAXIN IV 3 Beta-lactam, Penicillins amoxicillin 1 amoxicillin/clavulanate potassium 1 amoxicillin/clavulanate potassium er 1 ampicillin 1 ampicillin sodium inj 10gm, 125mg, 1gm 1 ampicillin-sulbactam 1 AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML 3 BACTOCILL IN DEXTROSE INJ 0; 1GM/50ML 3 9

16 BACTOCILL IN DEXTROSE INJ 0; 2GM/50ML 4 BICILLIN C-R 2 BICILLIN L-A 2 dicloxacillin sodium 1 nafcillin sodium inj 1gm 1 nafcillin sodium inj 10gm 4 NALLPEN/DEXTROSE INJ 0; 1GM/50ML 4 oxacillin sodium inj 2gm 1 oxacillin sodium inj 10gm 4 PENICILLIN G POTASSIUM IN ISO-OSMOTIC 3 DEXTROSE INJ 0; 40000UNIT/ML, 0; 60000UNIT/ML penicillin g potassium inj unit 1 penicillin g procaine 1 penicillin g sodium 4 penicillin v potassium 1 piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 1 4gm; 0.5gm UNASYN BULK PACK 3 UNASYN INJ 2GM; 1GM 3 ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 2 3GM/50ML; 0.375GM/50ML ZOSYN INJ 3GM; 0.375GM 3 Macrolides AZASITE 2 azithromycin pack, susr, tabs 1 azithromycin inj 500mg 1 BIAXIN 3 clarithromycin er 1 clarithromycin susr, tabs 1 DIFICID 4 PA E.E.S E.E.S. GRANULES 2 ERY-TAB 2 ERYPED ERYPED ERYTHROCIN LACTOBIONATE INJ 500MG 4 ERYTHROCIN STEARATE 2 erythromycin base tabs 1 erythromycin ethylsuccinate tabs 1 erythromycin oint 5mg/gm 1 ilotycin 1 KETEK 2 PA PCE TBEC 500MG 2 PCE TBEC 333MG 3 ZITHROMAX 3 ZITHROMAX TRI-PAK 3 10

17 TIER ZITHROMAX Z-PAK 3 ZMAX 3 Quinolones AVELOX 3 AVELOX ABC PACK 3 BESIVANCE 2 CILOXAN OINT 2 CILOXAN SOLN 3 CIPRO I.V.-IN D5W INJ 400MG/200ML; 5% 3 CIPRO SUSR 2 ciprofloxacin er 1 ciprofloxacin hcl soln, tabs 1 ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1 ciprofloxacin susr 1 ciprofloxacin inj 400mg/40ml 1 CIPRO TABS 250MG, 500MG 3 FACTIVE 3 gatifloxacin 1 LEVAQUIN SOLN, TABS 3 levofloxacin 1 levofloxacin in d5w inj 5%; 500mg/100ml 1 MOXEZA 2 moxifloxacin hcl tabs 1 OCUFLOX 3 ofloxacin ophthalmic soln 0.3% 1 ofloxacin tabs 400mg 1 VIGAMOX 2 ZYMAXID 3 Sulfonamides BLEPH-10 3 SILVADENE 3 silver sulfadiazine 1 sodium sulfacetamide soln 1 ssd 1 sulfacetamide sodium oint 10% 1 sulfadiazine tabs 1 Tetracyclines ADOXA CAPS 4 demeclocycline hcl tabs 1 doxy doxycycline hyclate dr 1 doxycycline hyclate caps 100mg, 50mg 1 doxycycline hyclate inj 100mg 1 doxycycline hyclate tabs 100mg 1 doxycycline monohydrate 1 doxycycline caps, susr 1 REQUIREMENTS/LIMITS 11

18 MINOCIN CAPS 100MG, 50MG 3 minocycline hcl er 1 minocycline hcl caps, tabs 1 SOLODYN TB24 105MG, 115MG, 55MG, 65MG, 80MG 4 tetracycline hcl caps 1 VIBRAMYCIN 3 Anticonvulsants Anticonvulsants, Other KEPPRA XR 4 KEPPRA SOLN 4 KEPPRA TABS 250MG 3 KEPPRA TABS 1000MG, 500MG, 750MG 4 levetiracetam 1 levetiracetam er 1 POTIGA TABS 50MG 2 QL (270 EA per 30 days) PA POTIGA TABS 200MG, 300MG, 400MG 4 QL (90 EA per 30 days) PA Calcium Channel Modifying Agents CELONTIN 2 ethosuximide 1 ZARONTIN 3 ZONEGRAN CAPS 25MG 3 ZONEGRAN CAPS 100MG 4 zonisamide 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 2mg 1 QL (300 EA per 30 days) clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg 1 QL (90 EA per 30 days) clonazepam tabs 2mg 1 QL (300 EA per 30 days) clonazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) DEPACON 3 DEPAKENE CAPS 3 DEPAKENE SYRP 4 DEPAKOTE 3 DEPAKOTE ER 3 DEPAKOTE SPRINKLES 3 DIASTAT ACUDIAL 3 DIASTAT PEDIATRIC 3 DIAZEPAM GEL 2.5MG 2 diazepam gel 10mg, 20mg 1 divalproex sodium 1 divalproex sodium dr 1 divalproex sodium er 1 gabapentin caps 1 gabapentin soln 1 QL (2160 ML per 30 days) gabapentin tabs 800mg 1 QL (135 EA per 30 days) gabapentin tabs 600mg 1 QL (180 EA per 30 days) GABITRIL TABS 12MG, 16MG 2 12

19 GABITRIL TABS 2MG, 4MG 3 KLONOPIN TABS 2MG 3 QL (300 EA per 30 days) KLONOPIN TABS 0.5MG, 1MG 3 QL (90 EA per 30 days) MYSOLINE 4 NEURONTIN CAPS, SOLN 3 NEURONTIN TABS 4 ONFI SUSP 2 ONFI TABS 10MG 2 ONFI TABS 20MG 4 phenobarbital elix 1 QL (1500 ML per 30 days) PA phenobarbital tabs 100mg 1 QL (120 EA per 30 days) PA phenobarbital tabs 97.2mg 1 QL (60 EA per 30 days) PA phenobarbital tabs 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 1 QL (90 EA per 30 days) PA 64.8mg primidone tabs 1 SABRIL 4 PA tiagabine hydrochloride 1 valproate sodium inj 1 valproic acid caps, syrp 1 Glutamate Reducing Agents felbamate tabs 1 PA felbamate susp 4 PA FELBATOL 4 PA FYCOMPA TABS 10MG, 12MG, 8MG 2 FYCOMPA TABS 4MG, 6MG 4 FYCOMPA TABS 2MG 4 QL (30 EA per 30 days) LAMICTAL CHEWABLE DISPERSIBLE CHEW 5MG 3 LAMICTAL CHEWABLE DISPERSIBLE CHEW 25MG 4 LAMICTAL ODT TBDP 200MG, 25MG 3 LAMICTAL ODT TBDP 50MG 3 QL (30 EA per 30 days) LAMICTAL ODT TBDP 100MG 3 QL (90 EA per 30 days) LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 2 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT 4 TAKING VALPROATE LAMICTAL STARTER/TAKING VALPROATE 2 LAMICTAL XR KIT 2 LAMICTAL XR TB24 4 LAMICTAL TABS 150MG 3 LAMICTAL TABS 100MG, 200MG, 25MG 4 lamotrigine er 1 lamotrigine odt tbdp 200mg, 25mg 1 lamotrigine odt tbdp 50mg 1 QL (30 EA per 30 days) lamotrigine odt tbdp 100mg 1 QL (90 EA per 30 days) lamotrigine chew, tabs 1 QUDEXY XR CS24 200MG 3 QL (240 EA per 30 days) ST QUDEXY XR CS24 150MG 3 QL (300 EA per 30 days) ST 13

20 QUDEXY XR CS24 100MG, 25MG, 50MG 3 QL (60 EA per 30 days) ST TOPAMAX SPRINKLE CPSP 15MG 3 TOPAMAX SPRINKLE CPSP 25MG 4 TOPAMAX TABS 25MG, 50MG 3 TOPAMAX TABS 100MG, 200MG 4 topiramate er cs24 200mg 1 QL (240 EA per 30 days) topiramate er cs24 150mg 1 QL (300 EA per 30 days) topiramate er cs24 100mg, 25mg, 50mg 1 QL (60 EA per 30 days) topiramate cpsp, tabs 1 TROKENDI XR CP24 100MG, 25MG, 50MG 2 TROKENDI XR CP24 200MG 4 Sodium Channel Agents APTIOM TABS 200MG 2 QL (60 EA per 30 days) APTIOM TABS 400MG 4 QL (30 EA per 30 days) APTIOM TABS 600MG, 800MG 4 QL (60 EA per 30 days) BANZEL 4 carbamazepine er 1 carbamazepine chew, susp, tabs 1 CARBATROL 3 CEREBYX INJ 500MG PE/10ML 3 DILANTIN INFATABS 3 DILANTIN DILANTIN CAPS 30MG 2 DILANTIN CAPS 100MG 3 epitol 1 fosphenytoin sodium inj 100mg pe/2ml 1 oxcarbazepine 1 OXTELLAR XR 2 PEGANONE 2 PHENYTEK 3 phenytoin sodium extended 1 phenytoin sodium inj 1 phenytoin chew, susp 1 TEGRETOL-XR TB12 100MG 2 TEGRETOL-XR TB12 200MG, 400MG 3 TEGRETOL SUSP, TABS 3 TRILEPTAL SUSP 4 TRILEPTAL TABS 150MG, 300MG 3 TRILEPTAL TABS 600MG 4 VIMPAT 3 Antidementia Agents Antidementia Agents, Other ergoloid mesylates tabs 1 PA Cholinesterase Inhibitors ARICEPT 3 ST donepezil hcl 1 14

21 EXELON CAPS, PT24 3 ST galantamine hydrobromide 1 RAZADYNE ER 3 ST RAZADYNE TABS 3 ST rivastigmine tartrate 1 N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA 2 PA NAMENDA TITRATION PAK 2 PA NAMENDA XR 2 QL (30 EA per 30 days) PA NAMENDA XR TITRATION PACK 2 QL (30 EA per 30 days) PA Antidepressants Antidepressants, Other APLENZIN TB24 174MG, 348MG 2 QL (30 EA per 30 days) ST APLENZIN TB24 522MG 4 QL (30 EA per 30 days) ST bupropion hcl sr tb12 100mg 1 QL (120 EA per 30 days) bupropion hcl sr tb12 150mg, 200mg 1 QL (60 EA per 30 days) bupropion hcl xl tb24 300mg 1 QL (30 EA per 30 days) bupropion hcl xl tb24 150mg 1 QL (90 EA per 30 days) bupropion hcl tabs 100mg 1 QL (120 EA per 30 days) bupropion hcl tabs 75mg 1 QL (90 EA per 30 days) chlordiazepoxide/amitriptyline 1 PA FORFIVO XL 2 QL (30 EA per 30 days) ST maprotiline hcl 1 mirtazapine 1 QL (30 EA per 30 days) mirtazapine odt 1 QL (30 EA per 30 days) olanzapine/fluoxetine 1 perphenazine/amitriptyline 1 PA REMERON 3 QL (30 EA per 30 days) ST REMERON SOLTAB 3 QL (30 EA per 30 days) ST SYMBYAX CAPS 25MG; 3MG, 25MG; 6MG, 50MG; 6MG 3 SYMBYAX CAPS 25MG; 12MG, 50MG; 12MG 4 WELLBUTRIN SR TB12 100MG 3 QL (120 EA per 30 days) ST WELLBUTRIN SR TB12 150MG, 200MG 3 QL (60 EA per 30 days) ST WELLBUTRIN XL TB24 300MG 4 QL (30 EA per 30 days) ST WELLBUTRIN XL TB24 150MG 4 QL (90 EA per 30 days) ST WELLBUTRIN TABS 100MG 3 QL (120 EA per 30 days) ST WELLBUTRIN TABS 75MG 3 QL (90 EA per 30 days) ST Monoamine Oxidase Inhibitors EMSAM 4 QL (30 EA per 30 days) ST MARPLAN 2 ST NARDIL 3 QL (180 EA per 30 days) ST PARNATE 4 ST phenelzine sulfate tabs 1 tranylcypromine sulfate 1 SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor) 15

22 BRINTELLIX 2 QL (30 EA per 30 days) CELEXA 3 QL (30 EA per 30 days) ST citalopram hydrobromide tabs 1 QL (30 EA per 30 days) citalopram hydrobromide soln 1 QL (600 ML per 30 days) CYMBALTA 3 QL (60 EA per 30 days) ST DESVENLAFAXINE ER 2 ST duloxetine hcl cpep 20mg, 30mg, 60mg 1 QL (60 EA per 30 days) EFFEXOR XR CP24 150MG 3 QL (60 EA per 30 days) ST EFFEXOR XR CP MG, 75MG 3 QL (90 EA per 30 days) ST escitalopram oxalate tabs 1 QL (30 EA per 30 days) escitalopram oxalate soln 1 QL (600 ML per 30 days) FETZIMA 2 QL (30 EA per 30 days) ST FETZIMA TITRATION PACK 2 QL (28 EA per 28 days) ST fluoxetine dr 1 QL (4 EA per 28 days) fluoxetine hcl caps 20mg 1 QL (120 EA per 30 days) fluoxetine hcl caps 40mg 1 QL (60 EA per 30 days) fluoxetine hcl caps 10mg 1 QL (90 EA per 30 days) fluoxetine hcl soln 1 QL (600 ML per 30 days) fluoxetine hcl tabs 20mg 1 QL (120 EA per 30 days) fluoxetine hcl tabs 60mg 1 QL (30 EA per 30 days) fluoxetine hcl tabs 10mg 1 QL (90 EA per 30 days) fluvoxamine maleate 1 QL (90 EA per 30 days) fluvoxamine maleate er 1 QL (60 EA per 30 days) KHEDEZLA 2 ST LEXAPRO TABS 3 QL (30 EA per 30 days) ST LEXAPRO SOLN 3 QL (600 ML per 30 days) ST nefazodone hcl 1 paroxetine hcl er tb mg 1 QL (180 EA per 30 days) PA paroxetine hcl er tb mg 1 QL (60 EA per 30 days) PA paroxetine hcl er tb24 25mg 1 QL (90 EA per 30 days) PA paroxetine hcl tabs 10mg 1 QL (30 EA per 30 days) PA paroxetine hcl tabs 40mg 1 QL (45 EA per 30 days) PA paroxetine hcl tabs 30mg 1 QL (60 EA per 30 days) PA paroxetine hcl tabs 20mg 1 QL (90 EA per 30 days) PA PAXIL CR TB MG 3 QL (180 EA per 30 days) PA PAXIL CR TB MG 3 QL (60 EA per 30 days) PA PAXIL CR TB24 25MG 3 QL (90 EA per 30 days) PA PAXIL SUSP 2 QL (900 ML per 30 days) ST PA PAXIL TABS 10MG 3 QL (30 EA per 30 days) ST PA PAXIL TABS 40MG 3 QL (45 EA per 30 days) ST PA PAXIL TABS 30MG 3 QL (60 EA per 30 days) ST PA PAXIL TABS 20MG 3 QL (90 EA per 30 days) ST PA PEXEVA TABS 10MG, 20MG 3 QL (30 EA per 30 days) PA PEXEVA TABS 40MG 3 QL (45 EA per 30 days) PA PEXEVA TABS 30MG 3 QL (60 EA per 30 days) PA PRISTIQ TB24 100MG 2 QL (120 EA per 30 days) ST 16

23 PRISTIQ TB24 50MG 2 QL (30 EA per 30 days) ST PROZAC WEEKLY 3 QL (4 EA per 28 days) ST PROZAC CAPS 20MG 3 QL (120 EA per 30 days) ST PROZAC CAPS 40MG 3 QL (60 EA per 30 days) ST PROZAC CAPS 10MG 3 QL (90 EA per 30 days) ST SARAFEM 2 ST sertraline hcl conc 1 QL (300 ML per 30 days) sertraline hcl tabs 50mg 1 QL (30 EA per 30 days) sertraline hcl tabs 25mg 1 QL (45 EA per 30 days) sertraline hcl tabs 100mg 1 QL (60 EA per 30 days) trazodone hcl 1 venlafaxine hcl er cp24 150mg 1 QL (60 EA per 30 days) venlafaxine hcl er cp mg, 75mg 1 QL (90 EA per 30 days) venlafaxine hcl er tb24 225mg 1 QL (30 EA per 30 days) venlafaxine hcl er tb24 150mg 1 QL (60 EA per 30 days) venlafaxine hcl er tb mg, 75mg 1 QL (90 EA per 30 days) venlafaxine hcl tabs 50mg 1 QL (210 EA per 30 days) venlafaxine hcl tabs 100mg, 25mg, 37.5mg, 75mg 1 QL (90 EA per 30 days) VIIBRYD 2 QL (30 EA per 30 days) ZOLOFT CONC 3 QL (300 ML per 30 days) ST ZOLOFT TABS 50MG 3 QL (30 EA per 30 days) ST ZOLOFT TABS 25MG 3 QL (45 EA per 30 days) ST ZOLOFT TABS 100MG 3 QL (60 EA per 30 days) ST SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor PRISTIQ TB24 25MG 2 QL (30 EA per 30 days) ST Tricyclics amitriptyline hcl tabs 1 PA amoxapine 1 PA ANAFRANIL CAPS 75MG 3 PA ANAFRANIL CAPS 25MG, 50MG 4 PA clomipramine hcl caps 1 PA desipramine hcl tabs 1 PA doxepin hcl caps, conc 1 PA imipramine hcl tabs 1 PA imipramine pamoate 1 PA NORPRAMIN 3 ST PA nortriptyline hcl caps, soln 1 PA PAMELOR 4 ST PA protriptyline hcl 1 PA SURMONTIL 2 PA TOFRANIL-PM CAPS 125MG, 150MG, 75MG 3 PA TOFRANIL-PM CAPS 100MG 4 PA TOFRANIL TABS 10MG 3 PA TOFRANIL TABS 25MG, 50MG 4 PA Antiemetics 17

24 Antiemetics, Other AKYNZEO 2 PA compro 1 meclizine hcl tabs 1 metoclopramide hcl inj, oral soln, tabs 1 metoclopramide odt 1 METOZOLV ODT TBDP 5MG 3 ST prochlorperazine 1 prochlorperazine edisylate inj 1 prochlorperazine maleate tabs 1 REGLAN 3 TIGAN CAPS 3 PA TRANSDERM-SCOP 2 QL (10 EA per 30 days) ST trimethobenzamide hcl caps 1 PA Emetogenic Therapy Adjuncts ALOXI 4 ST ANZEMET INJ 2 ST ANZEMET TABS 100MG 2 QL (3 EA per 3 days) B/D ANZEMET TABS 50MG 4 QL (6 EA per 3 days) B/D CESAMET 4 QL (20 EA per 3 days) PA dronabinol caps 10mg 1 PA dronabinol caps 2.5mg, 5mg 1 QL (180 EA per 30 days) PA EMEND CAPS 125MG, 40MG 3 QL (1 EA per 1 days) PA EMEND CAPS 80MG 3 QL (2 EA per 1 days) PA EMEND CAPS 0 3 QL (3 EA per 1 days) PA granisetron hcl tabs 1 QL (6 EA per 3 days) B/D granisetron hcl inj 0.1mg/ml, 1mg/ml 1 MARINOL CAPS 2.5MG 3 QL (180 EA per 30 days) PA MARINOL CAPS 10MG 4 PA MARINOL CAPS 5MG 4 QL (180 EA per 30 days) PA ondansetron hcl oral soln 1 QL (900 ML per 30 days) B/D ondansetron hcl inj 4mg/2ml 1 ondansetron hcl tabs 24mg 1 B/D ondansetron hcl tabs 4mg 1 QL (180 EA per 30 days) B/D ondansetron hcl tabs 8mg 1 QL (90 EA per 30 days) B/D ondansetron odt tbdp 4mg 1 QL (180 EA per 30 days) B/D ondansetron odt tbdp 8mg 1 QL (90 EA per 30 days) B/D SANCUSO 4 QL (2 EA per 28 days) ST ZOFRAN ODT TBDP 4MG 4 QL (180 EA per 30 days) B/D ZOFRAN ODT TBDP 8MG 4 QL (90 EA per 30 days) B/D ZOFRAN ORAL SOLN 4 QL (900 ML per 30 days) B/D ZOFRAN INJ 4 ST ZOFRAN TABS 4MG 4 QL (180 EA per 30 days) B/D ZOFRAN TABS 8MG 4 QL (90 EA per 30 days) B/D ZUPLENZ FILM 8MG 2 QL (90 EA per 30 days) ST B/D ZUPLENZ FILM 4MG 4 QL (180 EA per 30 days) ST B/D 18

25 Antifungals Antifungals ABELCET 4 B/D AMBISOME 4 B/D amphotericin b 1 B/D ANCOBON 4 AVC 2 CANCIDAS INJ 70MG 2 CANCIDAS INJ 50MG 4 ciclopirox 1 ciclopirox nail lacquer 1 ciclopirox olamine crea 1 clotrimazole crea, soln, troc 1 CRESEMBA 4 PA DIFLUCAN 3 econazole nitrate crea 1 ERAXIS INJ 100MG 4 ERTACZO 3 EXELDERM 2 EXTINA 3 fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1 fluconazole susr, tabs 1 flucytosine 4 GRIS-PEG 3 griseofulvin microsize 1 griseofulvin ultramicrosize 1 GYNAZOLE-1 2 itraconazole caps 1 PA JUBLIA 3 QL (8 ML per 30 days) KERYDIN 3 ketoconazole crea, sham, tabs 1 LAMISIL 3 LOPROX SHAMPOO 3 LUZU 2 MENTAX 2 miconazole 3 supp 1 MYCAMINE 4 naftifine hcl 1 NAFTIN 3 NATACYN 2 NIZORAL 3 NOXAFIL SUSP, TBEC 4 PA nyamyc 1 nystatin/triamcinolone 1 nystatin crea, oint, powd, susp, tabs 1 nystop 1 19

26 ONMEL 4 PA OXISTAT 2 SPORANOX 4 PA SPORANOX PULSEPAK 3 PA TERAZOL 3 CREA 3 TERAZOL 7 3 terbinafine hcl tabs 1 terconazole 1 VFEND 4 VFEND IV 3 voriconazole inj 1 voriconazole susr 4 voriconazole tabs 50mg 1 voriconazole tabs 200mg 4 zazole crea 1 Antigout Agents Antigout Agents allopurinol tabs 1 ALOPRIM 2 COLCHICINE CAPS, TABS 2 QL (120 EA per 30 days) COLCRYS 2 QL (120 EA per 30 days) probenecid/colchicine 1 probenecid tabs 1 ULORIC TABS 40MG 2 QL (30 EA per 30 days) ST ULORIC TABS 80MG 2 ST ZYLOPRIM 3 Antimigraine Agents Ergot Alkaloids CAFERGOT 2 dihydroergotamine mesylate inj 1 dihydroergotamine mesylate nasal soln 4 ERGOMAR 2 QL (20 EA per 28 days) MIGERGOT 4 QL (20 EA per 28 days) MIGRANAL 4 Serotonin (5-HT) 1b/1d Receptor Agonists ALSUMA 4 QL (4 ML per 30 days) AMERGE 3 QL (9 EA per 30 days) ST AXERT 2 QL (12 EA per 30 days) ST FROVA 2 QL (18 EA per 30 days) ST IMITREX STATDOSE REFILL INJ 4MG/0.5ML 3 QL (4 ML per 30 days) ST IMITREX STATDOSE REFILL INJ 6MG/0.5ML 4 QL (4 ML per 30 days) ST IMITREX NASAL SOLN 3 QL (6 EA per 30 days) ST IMITREX TABS 3 QL (9 EA per 30 days) ST IMITREX INJ 4 QL (4 ML per 30 days) ST MAXALT 3 QL (12 EA per 30 days) ST MAXALT-MLT 3 QL (12 EA per 30 days) ST 20

27 naratriptan hcl 1 QL (9 EA per 30 days) RELPAX 2 QL (6 EA per 30 days) ST rizatriptan benzoate 1 QL (12 EA per 30 days) rizatriptan benzoate odt 1 QL (12 EA per 30 days) sumatriptan succinate tabs 1 QL (9 EA per 30 days) sumatriptan succinate inj 6mg/0.5ml 1 QL (4 ML per 30 days) sumatriptan soln 1 QL (6 EA per 30 days) SUMAVEL DOSEPRO INJ 4MG/0.5ML 2 QL (4 ML per 30 days) SUMAVEL DOSEPRO INJ 6MG/0.5ML 4 QL (4 ML per 30 days) TREXIMET 4 ST zolmitriptan odt 1 QL (9 EA per 30 days) zolmitriptan tabs 1 QL (9 EA per 30 days) ZOMIG NASAL SPRAY 2 QL (6 EA per 30 days) ST ZOMIG ZMT TBDP 2.5MG 3 QL (9 EA per 30 days) ST ZOMIG ZMT TBDP 5MG 4 QL (9 EA per 30 days) ST ZOMIG TABS 4 QL (9 EA per 30 days) ST ZOMIG SOLN 2.5MG 2 QL (18 EA per 30 days) ST Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL 2 MESTINON TIMESPAN 2 MESTINON SYRP 2 MESTINON TABS 4 pyridostigmine bromide tabs 1 Antimycobacterials Antimycobacterials, Other DAPSONE TABS 2 MYCOBUTIN 4 rifabutin 1 Antituberculars CAPASTAT SULFATE 3 ethambutol hcl tabs 1 isoniazid inj, syrp, tabs 1 MYAMBUTOL TABS 400MG 3 PASER 3 PRIFTIN 3 pyrazinamide tabs 1 RIFADIN CAPS 3 RIFADIN INJ 4 RIFAMATE 3 rifampin caps, inj 1 RIFATER 3 SIRTURO 4 PA TRECATOR 3 Antineoplastics Alkylating Agents 21